Provider Demographics
NPI:1043395981
Name:DR CHRIS BOSEOVSKI DMD LLC
Entity Type:Organization
Organization Name:DR CHRIS BOSEOVSKI DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:BACH IN PSYCH
Authorized Official - Phone:570-622-0386
Mailing Address - Street 1:PO 1019
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901
Mailing Address - Country:US
Mailing Address - Phone:570-622-0386
Mailing Address - Fax:570-622-0484
Practice Address - Street 1:1349 W MARKET ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2282
Practice Address - Country:US
Practice Address - Phone:570-622-0386
Practice Address - Fax:570-622-0484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0352061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA215153OtherCIGNA
PA1181283OtherGATEWAY
PA838906OtherAETNA
PA0018864420002Medicaid
PA1589307OtherUNITED CONCORDIA
PA174855OtherCIGNA
PW158984OtherUNISON
PA871884OtherAETNA